Healthcare Provider Details

I. General information

NPI: 1871610618
Provider Name (Legal Business Name): KEITH A VAUGHN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SCENIC DR
ROGERSVILLE TN
37857-2452
US

IV. Provider business mailing address

161 CORALWOOD DR
KINGSPORT TN
37663-2709
US

V. Phone/Fax

Practice location:
  • Phone: 423-921-7224
  • Fax: 423-921-7227
Mailing address:
  • Phone: 423-239-4366
  • Fax: 423-224-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0000003655
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0105006341
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: